Healthcare Provider Details

I. General information

NPI: 1013353275
Provider Name (Legal Business Name): BLOOM FAMILY CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 E GRAND AVE
ESCONDIDO CA
92025-4402
US

IV. Provider business mailing address

633 E GRAND AVE
ESCONDIDO CA
92025-4402
US

V. Phone/Fax

Practice location:
  • Phone: 760-747-4737
  • Fax: 760-747-9905
Mailing address:
  • Phone: 760-747-4737
  • Fax: 760-747-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC21341
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC20522
License Number StateCA

VIII. Authorized Official

Name: TERESA L GUTA
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 760-747-4737